M4 Comprehensive Clinical Assessment

(CCA)

Practical Advice2009

M4 CCAThe mission of the M4 CCA is

to ensure that students are competent in the

fundamental clinical skills necessary to provide

excellent, effective, and safe patient care as a PGY1

trainee.

Goals:M4 CCA vs. USMLE Step

2 CS•The M4 CCA is designed to

measure student competency across U of M specific intended learning outcomes.

•Therefore the M4 CCA is similar to but differs from the Step 2 CS Exam in several ways.

Continued: M4 CCA vs. USMLE Step 2

CS• The M4 CCA includes radiographic

studies, EKGs, and EBM.

• Each station on the M4 CCA may or may not be followed by post-encounter note or exercise.

• Similar to the Step 2 CS, you may need to interview parents.

Content of M4 CCA: Part 1 - Computer Based

Exam Content includes:

• EBM• EKG• Imaging•There may be “pilot” components to the computer based exam

Content of M4 CCA: Part 2 - Clinical Exam

• Cases are drawn from a blueprint and include important symptoms and diagnoses, presenting complaints, and conditions – balanced by age and gender.

• Settings include in-patient unit, urgent care and outpatient clinic sites.

• Approximately 10 -12 stations.

• There may be “pilot” stations – whichyou will not be graded on.

Tasks• Many stations include a focused

history and/or physical exam.

• There may or may not be a post-encounter note or exercise following the patient encounter.

• Be sure to read the instructions on the door and understand the tasks at each station before entering the room.

Standardized Patient ScoringSpecific checklists and rating scales

are used to record examinee’sperformance in the following areas:

1. Content:– Important history items and/or physical

exam items– Personal Manner (e.g. hand washing and

draping)

2. Communication Skills: – Open the interview (appropriate

introductions, identification of cc, agenda setting)

SP Scoring: Communication Skills Continued:

– Assess the patient’s problem (accurate and efficient data collection, and understanding of the pt)

– Verbal and Non-verbal relationship building skills (empathy, support, partnership, respect, and appropriate eye contact, and body language)

– Manage the patient’s problems (achievement of pt understanding, involvement of pt in treatment process, affirmation of intent)

Warning

Any information from past CCA exams may

be misleading.

Overall Station Details

Content of Door Instructions

For each patient encounter, there will be door instructions that include:– Pt name, age, chief complaint and the site

where the patient is being seen (e.g. in-patient unit, urgent care or outpatient clinic.)

– Pt’s vital signs (can be trusted, do not need to re-take)

– List of specific tasks to be completed (hx, physical exam, etc.)

– Time allotted for the station - Notice if a post-encounter exercise will follow or not.

At the Door•Read instructions and understand

the tasks• Review patient’s name, CC, vital sx• Quickly formulate your checklist• Knock, enter room, and introduce

yourself as you would in the hospital setting, i.e. student doctor _______

• Address patient by his or her full name (first AND last name)

Timing of Patient Encounters:

History AND Physical Exam Stations

•Door instructions: 10-20 sec.•History taking: 7-8 minutes•Physical exam: 4-5 minutes•Discuss plan with pt/closure:

1-2 min.TOTAL = 15 minutes

Timing of Patient Encounters:

History taking only Stations• Door instructions: 10-20 sec.• History taking: 12-13 minutes• Discuss plan with pt/closure: 2-3

minutesTOTAL = 15 minutes

*Remember that you will not be doing pelvicor rectal exams on the M4 CCA or Step 2CS. However, if indicated you should let thepatient know that “you will return” to do thispart of the exam.

History Taking, Communication

and Physical Exam Details

Some Components of HPI•Chronology•Symptoms•Pertinent negatives•Relevant:

–PMH (include tx, hospitalizations)

–Medications (include OTC, supplements, herbs, etc.)

•Risk factors•Relevant ROS

HPI: Symptoms•Timing – onset, duration,

frequency•Location•Quality•Severity/Intensity•Aggravating factors•Alleviating factors•Associated symptoms

Assessing pediatric patients

PMH:–Birth hx–Feeding hx–Growth and development– Immunizations and screening–Childhood illnesses (acute or chronic)

–Social development

Past Medical Hx (PMH)

•Past medical illnesses•Past surgical illnesses•Psychiatric illnesses•Medications (include OTC,

supplements, herbs, etc.)

•Allergies

CommunicationReview of the CS Step 2 web-site re: thescoring of Communication subcomponentsmay be helpful in preparation for the M4CCA and Step 2 CS:

Subcomponents:1.Questioning skills2.Information sharing3.Professional manner and rapport

Click here for USMLE Step 2 CS Information

NOTE: Go to page 10 for a more detailed description of subcomponents.

Physical Exams• Perform relevant physical exam• May need to perform a breast exam•Do not need to perform pelvic or

rectal but if indicated, you need to inform the patient that it will be done later

• Also can indicate any further physical exam needed in the post-encounter note.

Other Useful Topics/Tools to

Review

Assessing Possible Depression

• Affect• Two-Question Depression

Screen:1. “Have you often been bothered by

feeling down, depressed, or hopeless?”2. “Have you often been bothered by little

interest or pleasure in doing things?”

• “SIGECAPS” mnemonic

Assessing Geriatric Patientshttp://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare

• ADLs (Activities of Daily Living)• IADLS (Instrumental Activities of Daily

Living)• Social supports• Living environment• Medications• Incontinence• Falls• Cognition• Affect

Assessing Geriatric patients: Geriatric Physical Assessment

http://www.med.umich.edu/i/geriatrics_center/UMGeriatricsCare

• Mobility:– Observed Gait– Timed up & Go Test

• Cognition:– Mini-Cog Exam– Mini Mental Status Exam (MMSE)

• Affect:– Two-Question Depression Screen– -SIGECAPS– Geriatric Depression Screen (GDS), use if handout is

available

Coma and Mental Status Changes

Review materials suggested:1. Coma examination video (Dr. Selwa in

LRC)

2. Gelb lecture syllabus from M2 year, lectures on Toxic metabolic disorders, Acute mental status changes.

3. Gelb Introduction to Clinical Neurology Chapter 11

Post-Encounter Exercise

Information

Post-Encounter Exercises

Post-encounter exercises occur at six stations and may include one of the following:– A post-encounter Note (PEN)

or– A brief post-encounter assessment

that asks you to make a decision and justify your conclusion (PEA)or

– A post-encounter verbal presentation (PEP)

Post-Encounter Note (PEN)

• Timing: after clinical encounter with Standardized Patient

• Time allotted: 15 minutes• Standard SOAP format:

– Subjective component– Objective– Assessment– Plan

• Assessment based on inclusion of relevant details, accuracy, and judgment

Post-Encounter Assessment (PEA)

• Timing: after clinical encounter with Standardized Patient

• Time allotted: 10 minutes

• Goal: to understand your assessment of the patient based on the patient encounter and the justification for your assessment and plan. Be as complete as you can.

Post-Encounter Presentation (PEP)

• Timing: after clinical encounter with Standardized Patient

• Time allotted: 15 minutes, includes:– Preparation time– Presentation time

• Goal: a 5 minute concise, relevant oral presentation to faculty member

• Assessment based on:– Content: relevance, accuracy, and

judgment– Communication

PEP: Components

3 components (PE is provided; not obtained from standardized patient):1. History2. Assessment3. Plan

PEP: History•Standard components:

–HPI (CC, associated relevant symptoms)

–Past Medical History–Family History (if relevant)–Social History–Medications

PEP: Assessment and Plan

•Assessment:–Differential Diagnosis, along with rationale

•Plan:–Further testing, with rationale–Initial therapy, with justification

Common Reasons for Station Failures

Common Reasons for Failure: History Taking

Incomplete history :– **Failure to consider broad

differential - premature closure.

– Failure to ask about PMH including medications, allergies.

– Failure to obtain FH, SH

Common Reasons for Failure: Physical Exam

• Not focused – too diffuse• Incomplete – omit important

elements• Exam must be focused, i.e.,

cannot do the whole physical, but must be thorough within that focused area

• Example: If a pt has chest pain, need to do elements of pulmonary, abdominal, musculoskeletal exam, etc.

Common Reasons for Failure: Communication

• Patient Communication (evaluated across all stations). The student:– Interrupts the patient or uses

medical terminology or jargon.– Fails to follow up on patient concerns

or response.– Fails to wash hands, extend table,

drape, and interact with the standardized patient as the student would interact with a real patient.

Common Reasons for Failure: Post Encounter Notes,

Assessments, and Presentations:

– Illogical–Omitting critical elements such as pertinent positives and negatives

–Premature closure re: diagnosis–Poorly written with non-standard abbreviations

Remediation & Retake

Information

Remediation In preparation for retaking a

station(s), you will be required to:

1. Review Educational Resources (electronically).

2. Complete a written electronic Self-Assessment of your performance by watching a reference video and comparing it to your own video.

*Some students may be required to attend a small group session or meet with a faculty member.

RetakesTwo retake exams will be offered

and you will be given the opportunity to select one of the following:– Wednesday, July 15– Wednesday, August 19

**Be sure that you are available for one of these dates as generally >50% of students need to re-take at least one station

GOOD LUCK!